Stimulation of myofibrillar protein degradation and expression of mRNA encoding the ubiquitin-proteasome system in C(2)C(12) myotubes by dexamethasone: effect of the proteasome inhibitor MG-132

Addition of the synthetic glucocorticoid, dexamethasone (Dex) to serum-deprived C(2)C(12) myotubes elicited time- and concentration-dependent changes in N(tau)-methylhistidine (3-MH), a marker of myofibrillar protein degradation. Within 24 h, 100 nM Dex significantly decreased the cell content of 3-MH and increased release into the medium. Both of these responses had increased in magnitude by 48 h and then declined toward basal values by 72 h. The increase in the release of 3-MH closely paralleled its loss from the cell protein. Furthermore, Dex also decreased the 3-MH:total cell protein ratio, suggesting that myofibrillar proteins were being preferentially degraded. Incubation of myotubes with the peptide aldehyde, MG-132, an inhibitor of proteolysis by the (ATP)-ubiquitin (Ub)-dependent proteasome, prevented both the basal release of 3-MH (>95%) and the increased release of 3-MH into the medium in response to Dex (>95%). Northern hybridization studies demonstrated that Dex also elicited similar time- and concentration-dependent increases in the expression of mRNA encoding two components (14 kDa E(2) Ub-conjugating enzyme and Ub) of the ATP-Ub-dependent pathway. The data demonstrate that Dex stimulates preferential hydrolysis of myofibrillar proteins in C(2)C(12) myotubes and suggests that the ATP-Ub-dependent pathway is involved in this response.

Geriatric assessment

A comprehensive geriatric assessment involves the evaluation of the physical, psychosocial, and environmental factors affecting the health of an elderly person. In the office setting a geriatric assessment is best accomplished by the use of screening questions, which are incorporated into the patient's medical questionnaire; the use of validated, brief screening tests that measure the patient's performance of daily living activities, cognition, nutritional status, and risk of falls; and a review of the patient's personal values and social support network. The screening assessment can be completed in an average of ten minutes by using self-administered questionnaires and brief performance-based measures of physical functioning. The comprehensive assessment performed on the initial visit with an elderly patient will help to (1) improve diagnostic accuracy, (2) guide the selection of interventions to restore or preserve health, (3) recommend an optimal environment for care, (4) predict health outcomes, and (5) monitor clinical change over time. The effectiveness of geriatric assessment has been demonstrated in clinical trials and is likely to be most effective when conducted by the patient's primary care physician.

Potential mechanisms of susceptibility to periodontitis in tobacco smokers

Tobacco smoking is probably the most important, controllable environmental risk factor in periodontitis. It results in changes in the vascular, inflammatory, immune and healing responses. The degree of exposure to tobacco smoking can be measured in pack years or by measuring serum cotinine and nicotine levels. In a previous paper we reported elevated levels of serum soluble intercellular adhesion molecule-1 (sICAM-1) in smokers, regardless of periodontal status. Elevated sICAM-1 has been found to be a risk marker for cardiovascular disease. In the present paper we report the short-term effects of an episode of smoking on blood flow and levels of sICAM-1. Human volunteers included non-smokers, light smokers and heavy smokers. Relative blood flow was monitored in the gingivae and forehead skin using a laser Doppler flowmeter and serum levels of sICAM-1, cotinine and nicotine measured before during and up to 60 min following an episode of smoking. We could not provide evidence to support the theory that there is localized vasoconstriction within the gingival tissues. In contrast, there was a significant increase in blood flow in the forehead skin of light smokers which was not observed in non-smoking controls or in heavy smokers, suggesting a long-term tolerance in this latter group. The level of sICAM-1 remained unchanged during this episode, further suggesting a long-term effect. In a parallel group of subjects, we were able to demonstrate a direct significant correlation between sICAM and serum cotinine levels. These observations may be relevant to aetiological mechanisms in periodontitis and other smoking-associated diseases.

Effects of functional status changes before and during hospitalization on nursing home admission of older adults

BACKGROUND

Functional status changes before and during hospitalization may have important effects on outcomes in older adults, but these effects are not well understood. We determined the influence of functional status changes on the risk of nursing home (NH) admission after hospitalization.

METHODS

Subjects were 551 general medical patients > or = 70 years old (66% female; mean age = 80 years) admitted from home to a large Midwestern teaching hospital. Functional status change measures were based on patients' need for assistance in five personal activities of daily living (ADL) 2 weeks prior to hospital admission, the day of admission, and the day of discharge. Sociodemographic and clinical characteristics were included in multivariate models predicting NH admission.

RESULTS

Functional status change categories were: stable in function before and during hospitalization (45% of study patients); decline in function before and improvement during hospitalization (26%); stable before and decline during hospitalization (15%); decline before and no improvement during hospitalization (13%). In multivariate analyses, patients in the decline-no improvement group (odds ratio [OR] = 3.19; 95% confidence interval [CI] = 1.46-6.96) and patients in the stable-decline group (OR = 2.77; 95% CI = 1.29-5.96) were at greater risk for NH admission than patients in the stable-stable group. In a multivariate model that controlled for ADL function at hospital discharge, functional status change was no longer statistically significantly associated with NH admission.

CONCLUSIONS

Discharge function is a key risk factor for NH admission among hospitalized older adults. Because functional status changes before and during hospitalization are key determinants of discharge function, they provide important clues about the potential to modify that risk. Functional recovery during a hospital stay after prior functional decline, and prevention of in-hospital functional decline after prior functional stability, are important targets for clinical intervention to minimize the risk of NH admission.

Potential intracellular targets for anabolic/anti-catabolic therapies

The intracellular signalling pathways controlling muscle protein synthesis and proteolysis are potential targets for anabolic/anti-catabolic therapy. In this review, we consider both the potentiation of the effect of anabolic hormones and suppression of the catabolic action of cytokines. Potential candidates, in particular isoforms of the protein kinase C family, and their role in the control of ribosomal action and the ubiquitin-proteasome proteolytic system are discussed.

Depressive symptoms and 3-year mortality in older hospitalized medical patients

BACKGROUND

Depressive symptoms are common in hospitalized older persons. However, their relation to long-term mortality is unclear because few studies have rigorously considered potential confounders of the relation between depression and mortality, such as comorbid illness, functional impairment, and cognitive impairment.

OBJECTIVE

To measure the association between depressive symptoms and long-term mortality in hospitalized older persons.

DESIGN

Prospective cohort study.

SETTING

General medical service of a teaching hospital.

PATIENTS

573 patients 70 years of age or older.

MEASUREMENTS

Depressive symptoms (Geriatric Depression Scale score), severity of acute illness (Acute Physiology and Chronic Health Evaluation II score), burden of comorbid illness (Charlson comorbidity index score), physical function (a nurse assessed dependence in six activities of daily living), and cognitive function (modified Mini-Mental State Examination) were measured at hospital admission. Mortality over the 3 years after admission was determined from the National Death Index. Mortality rates among patients with six or more depressive symptoms were compared with those among patients with five or fewer symptoms.

RESULTS

The mean age of the patients was 80 years; 68% of patients were women. Patients with six or more depressive symptoms had greater comorbid illness, functional impairment, and cognitive impairment at admission than patients with fewer depressive symptoms. Three-year mortality was higher in patients with six or more depressive symptoms (56% compared with 40%; hazard ratio, 1.56 [95% CI, 1.22 to 2.00]; P < 0.001). After adjustment for age, acute illness severity, comorbid illness, functional impairment, and cognitive impairment at the time of admission, patients with six or more depressive symptoms continued to have a higher mortality rate during the 3 years after admission (hazard ratio, 1.34 [CI, 1.03 to 1.73]). Although depressive symptoms contributed less to the mortality rate than did the total burden of comorbid medical illnesses, the excess mortality rate associated with depressive symptoms was greater than that conferred by one additional comorbid medical condition.

CONCLUSIONS

Depressive symptoms are associated with long-term mortality in older patients hospitalized with medical illnesses. This association is not fully explained by greater levels of comorbid illness, functional impairment, and cognitive impairment in patients with more depressive symptoms.

Non-surgical periodontal treatment with and without adjunctive metronidazole in smokers and non-smokers

AIM

To determine whether adjunctive metronidazole therapy would compensate for the poorer treatment response to scaling and root planing reported in smokers.

METHOD

A single-blind, randomised clinical trial of 28 smokers and 56 non-smokers, stratified for periodontitis disease severity and randomly allocated to 3 treatment groups: (1) Scaling and root planing using an ultrasonic scaler with local anaesthesia (SRP), (2) SRP+ metronidazole tabs 200 mg tds for 7 days, (3) SRP + 2 subgingival applications of 25% metronidazole gel. Probing depths (PD) and attachment levels (AL) were recorded with a Florida probe at baseline, 2 months and 6 months post treatment by a single examiner who was unaware of the treatment modality. Results were analysed for all sites with baseline probing depths equal to or greater than Florida probe recordings of 4.6 mm using analysis of variance.

RESULTS

Reductions in probing depth at 6 months were significantly less (p < 0.001) in the smokers (mean 1.23 mm, 95% confidence intervals = 1.05 to 1.40 mm) than in the non-smokers (1.92, 1.75 to 2.09 mm). Attachment level gains were approximately 0.55 mm and there was no statistically significant difference between smokers and non-smokers. There were no differences in any clinical measure in response to the three treatment regimens at 2 or 6 months for either smokers or non-smokers. A reduction in the proportion of spirochaetes was observed at 6 months which was less in smokers than in non-smokers (p = 0.034). Multiple linear regression analysis on probing depth at 6 months demonstrated that smoking was a significant explanatory factor (p < 0.001) for poor treatment outcome, whilst the presence or absence of adjunctive metronidazole was not (p = 0.620).

CONCLUSION

This study confirms that smokers have a poorer treatment response to SRP, regardless of the application of either systemic or locally applied adjunctive metronidazole.

The effects of maternal protein restriction on the growth of the rat fetus and its amino acid supply

Maternal protein deficiency causes fetal growth retardation which has been associated with the programming of adult disease. The growth of the rat fetus was examined when the mothers were fed on diets containing 180, 90 and 60 g protein/kg. The numbers of fetuses were similar in animals fed on the 180 and 90 g protein/kg diets but the number was significantly reduced in the animals fed on the 60 g protein/kg diet. The fetuses carried by the mothers fed on the 90 g protein/kg diet were 7.5% heavier than those of mothers fed on 180 g protein/kg diet on day 19 of gestation, but by day 21 the situation was reversed and the fetuses in the protein-deficient mothers were 14% smaller. Analysis of the free amino acids in the maternal serum showed that on day 19 the diets containing 90 and 60 g protein/kg led to threonine concentrations that were reduced to 46 and 20% of those found in animals fed on the control (180 g/kg) diet. The other essential amino acids were unchanged, except for a small decrease in the branched-chain amino acids in animals fed on the 60 g protein/kg diet. Both low-protein diets significantly increased the concentrations of glutamic acid+glutamine and glycine in the maternal serum. On day 21 the maternal serum threonine levels were still reduced by about one third in the group fed on the 90 g protein/kg diet. Dietary protein content had no effect on serum threonine concentrations in nonpregnant animals. Analysis of the total free amino acids in the fetuses on day 19 showed that feeding the mother on a low-protein diet did not change amino acid concentrations apart from a decrease in threonine concentrations to 45 and 26% of the control values at 90 and 60 g protein/ kg respectively. The results suggest that threonine is of particular importance to the protein-deficient mother and her fetuses. Possible mechanisms for the decrease in free threonine in both mother and fetuses and the consequences of the change in amino acid metabolism are discussed.

Translocation of protein kinase C isoforms in rat muscle in response to fasting and refeeding

Weanling rats were offered food ad libitum, or fasted for 18 h, or fasted and refed for times ranging from 5 to 30 min. Five protein kinase C (PKC) isoforms (alpha, epsilon, zeta, theta and mu) were detected in the hindlimb muscles by Western immunoblotting. PKC forms epsilon and theta were abundant in plantaris, but not in soleus muscle, and no difference in localization was detected between fed rats and those fasted for 18 h. PKC forms alpha and mu were affected by fasting and refeeding. PKC-mu was found only in the cytosolic fraction of the plantaris muscle of the fasted animal, but in the fully-fed animals it was also associated with the membrane fraction. The pattern of localization observed in the fully-fed state was restored in the fasted rats by 20 min refeeding. In contrast, PKC-alpha was not detected in the cytosolic fraction of the plantaris in fasted animals but rapidly reappeared there on refeeding, being restored to 20% and 80% of the fed value within 5 and 30 min of refeeding respectively. The timing of these changes was correlated with the increase in serum insulin concentration, which was significantly elevated above the fasted value by 5 min and at subsequent times. These data suggest a possible role for PKC isoforms alpha and mu in the metabolic changes that occur in skeletal muscle on transition between the fasted and the fed state.

Clinical intervention trials: the ACE unit

The loss of independent self-care by older patients during hospitalization for an acute illness can be modified by specific interventions. Acute care geriatric units appear to be the most effective intervention, but geriatric consultation on specific units, comprehensive discharge planning, and nutritional support also appear to have beneficial effects on clinical outcomes of hospitalization. These studies highlight the potential of geriatricians, in the setting of interdisciplinary care, to improve the process of patient care and to serve as directors of medical units that focus on management of acutely ill older patients.

Prevalence and patterns of physical restraint use in the acute care setting

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

Effect of loading on bone regenerated at implant dehiscence sites in humans

Few investigations have studied the long-term fate of bone formed following the technique of guided tissue regeneration. The aim of the present study was to evaluate bone fill around implant fixtures with dehiscence defects and to study its response to loading. Ten patients were treated with overdentures supported by 2 fixtures ad modum Brånemark. A third 7 mm x 3.75 mm diameter fixture was placed for the purposes of the study in the most anterior part of the mandible with a dehiscence defect of 4 to 5 mm on the buccal aspect (and 3 to 4 threads exposed) which was covered with a Gore-Tex membrane and buried beneath the mucosa. Fixtures were exposed after 5 months (stage 2), ball abutments connected and loaded through an overdenture for 1 year. Nine fixtures were functioning well after 1 year of loading, 6 of which were retrieved with a trephine for histological examination and compared with 6 unloaded fixtures retrieved in our previously reported study. The bone area filling the thread profiles (BA%) and the bone to metal contact (BMC%) were measured in the 3 most apical and 3 most coronal thread profiles on the buccal and lingual surfaces. Statistically significant higher BMC% (P < 0.01) were observed in loaded fixtures in the apical regions (buccal: loaded 51%, unloaded 25%; lingual: loaded 49%, unloaded 24%). Differences approached significance for the regeneration site (loaded 22%, unloaded 6%) but were no different for the coronal lingual region (loaded 28%, unloaded 20%). There were no differences for BA%. This study confirms that there is an increase in bone to metal contact with time and following fixture loading and that this may also occur with bone regenerated under Gore-Tex membranes.

Tools for assessing the frail elderly. Geriatric evaluation focuses on improving quality of life

Questionnaires and screening scales can help physicians identify physical, functional, social, and psychological problems often seen in frail elderly patients and also assess caregiver strain. Physicians should review with patients and caregivers the main findings and discuss plans for further evaluation and management, including laboratory tests, vaccinations, and advance directives.

Adjunctive systemic and locally delivered metronidazole in the treatment of periodontitis: a controlled clinical study

OBJECTIVE

To compare clinical and microbiological responses following non-surgical treatment of moderate to advanced adult periodontitis using subgingival scaling with and without adjunctive topical or systemic metronidazole.

DESIGN

A single blind randomised clinical trial of 90 subjects, stratified for periodontitis disease severity and smoking status, divided into three treatment groups: 1. Subgingival scaling using ultrasonic scalers and local anaesthesia; 2. Subgingival scaling using ultrasonic scalers and local anaesthesia plus seven days of systemic metronidazole (200 mg tds); 3. Subgingival scaling using ultrasonic scalers and local anaesthesia plus two applications of 25% metronidazole gel one week apart in all sites with probing depths more than 4 mm. Evaluations were made before treatment, and 8 weeks and 24 weeks post treatment.

MAIN OUTCOME MEASURES

Probing depths, probing attachment levels and bleeding on probing were measured using a Florida probe. Bacterial morphotypes were evaluated with darkfield microscopy. Results were analysed for all sites with baseline probing depths equal to or greater than Florida probe recordings of 4.6 mm using analysis of variance.

RESULTS

84 subjects completed the trial and the three treatment groups did not differ at baseline for any clinical parameter. Mean probing depths were reduced following treatment by greater than 1.6 mm (Group 1 = 1.68 mm, Group 2 = 1.62 mm, Group 3 = 1.74 mm at six months post treatment) but no significant differences were detected between treatment groups at any time point. Similarly, no significant differences were detectable between treatments for changes in mean probing attachment levels, bleeding on probing, plaque scores or proportions of bacterial morphotypes.

CONCLUSIONS

This study does not support the routine use of adjunctive metronidazole in the non-surgical treatment of periodontitis.

Development and cell fate in interspecific (Mus musculus/Mus caroli) orthotopic transplants of mouse molar tooth germs detected by in situ hybridization

Interpretation of results from previous tooth germ transplantation studies is limited by the inability to distinguish between donor and host cells unequivocally. Furthermore, ectopic transplantation sites have generally been used and the relevance of this to tooth development in situ is uncertain. The aim here was to determine cell fate in orthotopic tooth germ transplants using an interspecific mouse marker system. Mandibular first molar tooth germs were dissected from Mus musculus (CD1) and Mus caroli mice (age range 15-19 day embryo) and transplanted interspecifically into the alveolar crypt of extirpated first mandibular molars in neonatal M. musculus (CD1) and M. caroli hosts. Grafts were recovered at intervals up to 4 weeks postoperatively. Paraffin wax-embedded sections were examined using routine histological techniques and in situ hybridization with a biotinylated DNA probe (pmSat5) specific for M. musculus, to distinguish between donor and host cells. Development of M. musculus tooth germs in M. caroli mandibles and vice versa was similar and transplants progressed to incipient root formation. Vascularization of transplants was chimaeric, being donor-derived in the pulp and host-derived more peripherally. The investing soft tissues comprised a mixture of donor and host cells, predominantly donor. Donor cells were also found in the soft tissue of intertrabecular spaces in the surrounding bone, but alveolar osteocytes were almost entirely host-derived. Long-term survival of grafts was limited and few donor cells were present after 2 weeks. This study provides an unequivocal demonstration of the origin of all cells present in transplanted tooth germs.

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study

OBJECTIVE

To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline.

DESIGN

Three prospective cohort studies.

SETTING

Three university-affiliated teaching hospitals.

PATIENTS

Consecutive samples of 727 patients, aged 65 years and older.

MEASUREMENTS AND MAIN RESULTS

Delirium was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2).

CONCLUSIONS

Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline-even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.

Growth and metabolism of fetal and maternal muscles of adolescent sheep on adequate or high feed intake: possible role of protein kinase C-alpha in fetal muscle growth

From days 4-104 of pregnancy, adolescent sheep, weighing 43.7 (SE 0.87) kg were offered a complete diet at two different intakes (approximately 5 or 15 kg/week) designed to meet slightly, or well above, maternal maintenance requirements. The fetal and maternal muscles were taken on day 104 of pregnancy and analysed for total DNA, RNA and protein. Ewes offered a high intake to promote rapid maternal weight gain, weighed more (76.5 (SE 4.5) v 50.0 (SE 1.7) kg) and had muscles with a greater fresh weight, whilst their fetuses had smaller muscles, than those fed at a lower intake. Plantaris muscle of the ewes fed at the high intake contained more RNA and protein; again the opposite situation was found in the fetal muscle. On the higher maternal intakes, the DNA, RNA and protein contents of the fetal plantaris muscle were less than in fetuses of ewes fed at the lower intake. To investigate the possible mechanisms involved in this decrease in fetal muscle mass, cytosolic and membrane-associated muscle proteins were subjected to Western immunoblotting with antibodies to nine isoforms of protein kinase C (PKC), a family of enzymes known to play an important role in cell growth. Five PKC isoforms (alpha, epsilon, theta, mu, zeta) were identified in fetal muscle. One of these, PKC-alpha was located predominantly in the cytosolic compartment in the smaller fetuses of the ewes fed at a high plane of nutrition, but was present to a greater extent in the membranes of the more rapidly growing fetuses of the ewes fed at the lower intake. This was the only isoform to demonstrate nutritionally related changes in it subcellular compartmentation suggesting that it may mediate some aspects of the change in fetal growth rate.

The relation between health status changes and patient satisfaction in older hospitalized medical patients

OBJECTIVE

To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction.

DESIGN

Prospective cohort study.

SETTING AND PATIENTS

Subjects were 445 older medical patients (aged > or =70 years) hospitalized on the medical service of a teaching hospital.

MEASUREMENTS AND MAIN RESULTS

We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p = .46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p = .63). These findings were similar using the measure of global health and in multivariate analyses.

CONCLUSIONS

Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization.

Improving functional outcomes in older patients: lessons from an acute care for elders unit

BACKGROUND

Hospitalization often marks the beginning, and may be partially responsible for, a downward trajectory characterized by declining function, worsening quality of life, placement in a long term care facility, and death. At the University Hospitals of Cleveland, an Acute Care for Elders (ACE) unit that reengineered the process of caring for older patients (> or = 70 years of age) to improve functional outcomes was established in September 1990.

DESCRIPTION OF INTERVENTION

The general principles of ACE included an approach to care guided by the biopsychosocial model and recognition of the importance of fitting the hospital environment to the patient's needs. The design of the intervention was consistent with principles of comprehensive geriatric assessment and continuous quality improvement. Care, which focused on maintaining function, was directed by an interdisciplinary team that considered the patient's needs both at home and in the hospital. The major components of the ACE Unit intervention included patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review.

RESULTS

In a randomized trial comparing ACE with usual care, patients receiving ACE had improved functional outcomes at discharge. The costs to the hospital for ACE unit care were less than for usual care. The functional status of ACE and usual care patients was similar 90 days after discharge.

FUTURE DIRECTIONS

The ACE unit intervention is being expanded to preserve the improvements observed during the hospitalization in the outpatient setting. In addition, needs other than function which are critical to patients' long-term quality of life are being considered.

Signalling pathways regulating protein turnover in skeletal muscle

The protein content of skeletal muscle is determined by the relative rates of synthesis and degradation which must be regulated coordinately to maintain equilibrium. However, in conditions such as fasting where amino acids are required for gluconeogenesis, or in cancer cachexia, this equilibrium is disrupted and a net loss of protein ensues. This review, utilising studies performed in several situations, summarizes the current state of knowledge on the possible signalling pathways regulating protein turnover in skeletal muscle and highlights areas for future work.

Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study

OBJECTIVE

To identify factors associated with the occurrence of deliberate self-extubation and to describe associated patient outcomes.

DESIGN

Case-control study.

SETTING

ICUs of a national referral, tertiary medical center.

PARTICIPANTS

Fifty adult, intubated patients who had self-extubated from mechanical ventilatory support. Two control subjects who had not self-extubated were matched to each case based on age, gender, primary discharge diagnosis, and time hospitalized (within same quarter).

MEASUREMENTS

Standardized coding of medical record information, including demographic characteristics, clinical information, intubation and mechanical ventilation characteristics, medications, and selected laboratory indexes.

RESULTS

As compared to the control subjects, patients who self-extubated were more likely to be medical than surgical patients (p<0.001) and have a current history of smoking (p<0.05). Prior to the self-extubation, patients had a greater likelihood of hospital-acquired infections (p<0.001) or other hospital-acquired adverse events (p<0.001), abnormal (<10, >50 mg/dL) BUN (p<0.05), and abnormal (<20, >50 mm Hg) PaCO2 (p<0.05); they also were more likely to be restless or agitated (p<0.001), and more likely to be physically restrained (p<0.001). A logistic regression model demonstrated that presence of restlessness or agitation and presence of a hospital-acquired adverse event were independently associated with self-extubation from mechanical ventilatory support. In examining outcomes, as compared to the control subjects, those who self-extubated had longer lengths of stay in ICU and hospital, were more likely to need reintubation, and were more likely to suffer complications from intubation. However, none of the cases died within 48 h of self-extubation.

CONCLUSION

The results underscore the need for clinical guidelines for weaning and for monitoring patients at risk of self-extubation.

Implant placement: surgical techniques and considerations

Successful implant surgery largely depends on good planning and meticulous technique. The former requires an appreciation of the restorative requirements and visualization of the desired end result. This may be easier for the clinician who is delivering both aspects of treatment, but in other circumstances requires close collaboration between prosthodontist and surgeon. This paper focuses on the surgical techniques involved in implant surgery, because successful osseointegration is achievable only with careful surgical preparation.

When your patient is hospitalized: tips for primary care physicians

Outcomes of hospitalization of elderly patients can be improved through a systematic and comprehensive approach that physicians can incorporate into their practices. The first step is to recognize the patients who are at risk for functional decline in hospital, despite appropriate treatment of their acute illness. Many of these patients will present with one or more of the common geriatric syndromes, functional dependency, cognitive dysfunction (delirium), mood disorders (depression), and malnutrition. The next step is to avoid iatrogenic illness from diagnostic tests or medications and deconditioning due to immobility. Finally, discharge planning can help to ensure that patients receive needed services when they leave the hospital.

Paraneoplastic cerebellar degeneration. Case report and literature review

Paraneoplastic cerebellar degeneration (PCD) presents with acute or subacute onset of ataxia, dysarthria, and intention tremor. In patients older than 50 years, acute or subacute cerebellar degeneration is paraneoplastic in origin in 50% of cases. Paraneoplastic cerebellar degeneration most often precedes a potentially curable remote malignancy. Less often, PCD occurs in a patient with a known malignancy or heralds the onset of a recurrence. The presence of specific antibodies in serum samples helps to guide identification of the occult underlying malignancy. Physicians should entertain the diagnosis of PCD when older patients present with signs of cerebellar degeneration without an obvious cause. A systematic evaluation, including the selection of appropriate imaging and laboratory studies, will often enable physicians to identify the responsible cancer. However, because PCD can precede a cancer by months to years, periodic reevaluation is needed when the cancer remains occult.

A prospective study of Astra single tooth implants

A new design of single tooth implant (AstraTech, Molndal Sweden) featuring a microthreaded conical neck and TiO blast surface was evaluated clinically and radiographically after 2 years in function. Fifteen patients (age range 16 to 48) with missing maxillary anterior teeth (6 central incisors, 8 laterals, 1 bicuspid) had 4, 13 mm and 11, 15 mm implants placed under local anaesthesia and left for a period of 6 months before exposure and abutment connection/crown fabrication. All patients were seen at 4 to 6 monthly intervals for hygienist maintenance. Radiographs using Rinn holders and a long cone technique were taken at the crown insertion and after 1 year (14 subjects) and 2 years (12 subjects). All implants were successfully integrated at stage 2, and no implants have been lost. The internal conical seal design of the abutment/implant interface facilitated connection and there were no cases of abutment screw loosening. No soft tissue problems were observed, and the gingival morphology/health was well maintained. One crown was recemented after 18 months in function, and 1 crown was replaced because of a fracture to the porcelain incisal edge. At crown insertion, the mean bone level was 0.46 to 0.48 mm apical to the top of the implant and there were no statistically significant changes in the bone level over the 2 years of the study. In conclusion, the single tooth Astra implants were highly successful and bone changes within the first 2 years of function were comparable with other systems reporting high long-term success rates.